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CASE REPO R T Open Access
Tuberculosis of symphysis pubis in a 17 year old
male: a rare case presentation and review of
literature
Kamal Bali
*
, Vishal Kumar, Sandeep Patel, Aditya K Mootha
Abstract
Tuberculosis of symphysis pubis is a rare condition with hardly any report of such cases in the last decade. It is
necessary to distinguish the entity from more common ones like Osteitis pubis and Osteomyelitis of pubis symphy-
sis by urgent means in order to start the treatment early and thereby minimize morbidity and prevent complica-
tions. A rare case of tuberculosis of symphysis pubis in a 17 year old male is described. A high index of suspicion
along with an extensive workup including 3-phase bone scan and fine needle aspiration led to the diagnosis. The
patient had an excellent outcome following a complete course of multidrug chemotherapy for tuberculosis.
Background
Inflammation of the symphysis pubis can be non inf ec-
tive (osteitis pubis) or infecti ve(osteomyelitis) in nature.
Osteitis pubis is generally a self limiting inflammation of
the pubic symphysis secondary to trauma, pelvic sur-
gery, childbirth, or overuse[1]. Osteomyelitis of the
pubic symphysis is a rare condition, mostly bacterial in
etiology with risk factors being trauma, low grade infec-
tion, urological and gynaecological procedures, pelvic
malignancies and intrave nous drug use[2]. Tuberculosis
of the pubis symphysis is still uncommon with 9 cases
reported in the past 3 decades. However in the pre-che-
motherapy era in the earlier part of the century, upto
100 cases have been reported, which have all been diag-
nosed in advanced stages. We hereby report a case of
tuberculosis of pubic symphysis diagnosed early and
treated accordingly with Anti Tubercular Therapy.

Case presentation
A 17 year old male from low socioeconomic background
presented with complaints of a dull aching suprapubic
pain for the last 6 weeks. The pain radiated slightly to
the left groin. The pain was present continuously
throughout the day and it increased on standing and on
walking. However coughing, sneezing, voiding or
straining at stool did not exacerbate the symptoms.
Patient also had a history low grade evening rise in tem-
perature and weight loss of 6 Kg since past 2 months.
Therewasnohistorysuggestiveofanytrauma,athletic
exertion, infection or surgical procedure in the patient.
On examination deep tenderness was loc alized to pubic
symphysis. There was no locali sed swelling and palpa-
tion did not reveal any inguinal lymphadenopathy. Rec-
tal examination was also normal.
Laboratory tests revealed moderately increased white
cell counts (15,500/mm
3
), raised Erythrocyte Sedimenta-
tion Rate (62 mm/hr) & a positive C Reactive Protein.
Mantoux test was nonconclusive. Chest radiographs
were normal while the pelvic radiographs revealed rare-
faction and lytic changes in bilateral pubis, with more
involvement on left side ( Fig 1). An initial diagnosis of
osteitis pubis was made and the patient started on rest,
hot fomentation, NSAIDS and oral ciprofloxacin for
3 weeks.
However the patient did not respond to treatment. A
technetium 99 m l abeled scan (Fig 2) done at this stage

suggested inflammatory (likely i nfective) pathology of
the pubic symphysis. Perfusion and blood pool images
showed focal area of increased vascularity in the anterior
pelvic region. Delayed anterior, posterior and squatting
position static pelvic views showed increased tracer
uptake over the superior ramus extending down to the
body of left pubic bone and superior ramus of right
pubic bone as well. SPECT of pelvic region showed a
* Correspondence:
Deptt of Orthopaedics, PGIMER, Chandigarh, Postgraduate Institute of
Medical Education and Research, Sector 12, Chandigarh-160 012, India
Bali et al. Journal of Orthopaedic Surgery and Research 2010, 5:63
/>© 2010 Bali et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creative commons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properl y cited.
Figure 1 X ray pictures showing lytic foci in the symphysis pubis.
Figure 2 Technetium 99 m labeled bone scan with increased tracer uptake suggestive of inflammation and infection.
Bali et al. Journal of Orthopaedic Surgery and Research 2010, 5:63
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focus of intense tracer uptake over the superior ramus
and body of the left pubic bone and superior ramus of
the right pubic bone partially.
MRI of pelvis done also pointed towards infective
pathology of the symphysis pubis and further work up
showed a positive TB quantiferon test. A fine needle
aspiration (FNA) from the pub ic symphysis was per-
formed and it showed epithelioid cell clusters admixed
with histiocytes in a background of caseous necrosis and
little amount of blood ( Fig 3). In context of clinical fea-
tures and morphological feature on FNA smear, an Acid

Fast Bacilli(AFB) stain was performed and it demon-
strated multiple AFB positive bacteria (Fig 4).
Once histological evaluation confirmed the diagnosis
of tuberculosis, the patient w as started on multi drug
anti-tubercular chemotherapy comprising of Rifampicin,
Isoniazid, Ethambutol and Pyrizinamide. One month fol-
lowing the treatment, patient improved symptomatically
and started to gain weight. A repeat radiograph did not
show signs of progression. At last follow up after 12
months of chemothe rapy, the patient was symptom free
with a normal activity level without any signs of
recurrence.
Discussion
Osteoarticular tuberculosis is the second most common
form of extrapulmonary tuberculosis next to lymph
nodes and constitutes about 13% of all extrapulmonary
cases. It is generally accepted that osteoarticular
tuberculosis is the result o f a haematogenous or lym-
phatic spread from a reactivated latent focus, usually
pulmonary; however, previous infection is not always
encountered, and in only 40-50% of the cases, is it pos-
sible to demonstrate another active infection site. The
commonest site for skeletal tuberculosis is the spine fol-
lowed by t he hip, knee and ankle joints. Tuberculosis
can involve l iterally any bone or joint. With the rising
incidence of HIV and multi drug resistant strains, the
incidence of extrapulmonary tuberculosis and atypical
sites is on rise.
Tuberculosis of the pelvic girdle is primarily limited to
the sacroiliac synchondrosis and less frequently with iso-

lated involvement of ilium or ischial tubercle. Symphysis
pubis is an unusual site for tubercular infection. Thile-
sen was the first to describe tuberculosis of symphysis
pubis in 1855 followed by Hennies who presented 3
cases in an inaugu ral address in 1888. The various case
series and reviews on the subject are tabulated in
Table1.SomeofthelargestseriesarethosebySorell
[3] in 1932 (32 cases), Nicholson[3] in 1958 (11 cases),
Fares & Pagani [4] in 1966 (27 cases), Dybowski &
Makuchowa [5] in 1974 (32 cases). Since the introduc-
tion of effective anti-tubercular agents and the ge neral
decline in incidence of tuberculosis, involvement of the
pubis symphysis appear to have become very rare
indeed, if the number of reports indicate the incidence
of condition. There are only 9 cases reported in the last
3 decades [6-12].
Figure 3 FNA smear showing epithelioid cell clusters admixed with histiocytes in a background of caseous necrosis and little amount
of blood.
Bali et al. Journal of Orthopaedic Surgery and Research 2010, 5:63
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Almost all cases reported have been presented in
advanced stages with complications in the form of
abscess, sinuses opening to groin or vulva, mass and the
morbidity and mortality have been high. Most of the
authors have recommended thorough debridement and
toileting of the cavities as a treatment strategy. However
with the advent of anti-tubercular agents the recovery
and prognosis is b etter. In cases involving complete dis-
ruption of symphysis, some form of bridging in the
form of plate or bone graft has been advocated [12].

Differential diagnosis in such cases includes osteitis
pubis, osteomyelitis, and adolescent osteochondritis of
the symphysis pubis. It is essential to differentiate the
above entities as the treatment modality for each condi-
tion varies. It is even more important t o differentiate
osteomyelitis and tuberculosis as a delay in diagnosis
would result in extensive damage and hence add on to
morbidity and residual deformities.
The aetio logy of osteitis p ubis, or non-infective
inflammation of the pubis, is unknown. It is often asso-
ciated with rheumatic disease, exertion, atheletes, preg-
nancy, and urological or gynaecologi cal manipulation or
surgery [13]. The condition is a self remitting and treat-
ment is conserva tive in the form of NSAIDS, rest and
hot fomentation.
Pyogenic infection of the pubis might be a commoner
presentatation than tuberculosis of symphysis pubis.
Thepathogenesisisusuallyhematogenic dissemination
fol lowi ng trauma , abdominal, urological or gynaecologi-
cal procedures [2,13].The diagnosis of the condition
depends on isolation of the organism. Staph aureus is
Figure 4 An AFB stain showing multiple AFB +ve Tuberculous Bacilli.
Table 1 Tuberculosis of Symphysis Pubis: Cases reported
so far
YEAR AUTHOR NUMBER OF CASES
1888 Hennies 3
1929 Joachimouits 7
1930 Bean HC* 1
1932 Sorell 26
1935 Pytel 1

1938 Gregor 5
1939 Alpert 1
1949 Ficai 2
1951 Clavel 2
1955 Bevan 1
1955 Fairbank 1
1955 Read 1
1958 Nicholson OR 11
1964 Cadili G 1
1966 Fares & Pagani 27
1974 Dybowski & Makuchowa 32
1986 Ker NB 1
1990 Browner U 1
1991 Rozadilla A 1
1992 Mazameque L 1
1995 Tsay MH 1
1997 Benbouazza K 2
2001 Balsarkar DJ 1
2006 Bayrakci K 1
* one case report along with review of 15 cases.
Bali et al. Journal of Orthopaedic Surgery and Research 2010, 5:63
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themostcommonorganismisolatedfollowedbyPseu-
domonas. Knoeller et al [14] demonstrated that the
organism can be cultured even in cases which received
antibiotics. Treatment is with appropriate antibiotics
while advanced lesions require debridement and
toileting.
Clinical presentation however is similar in all the
above conditions and includes suprapubic pain some-

times radiating to the groins. Rectus and adductor
spasm accounts for the bending noted while standin g or
walking. Osteitis pubis is self remitting and the symp-
toms are slightly lighter and decrease with time. Bone
scintigraphy and MRI are more sensitive than plain
radiographs, especially in the early stages. Three-phase
bone scan can be helpful in the differential diagno sis of
osteitis and osteomyelitis [15]. Increased uptake in all
threephasespleadsforosteomyelitispubis,while
increased uptake in the mineralisation or delayed phase
only is typical for osteitis pubis. In the very early stages
of osteomyelitis pubis, the increased uptake may be lim-
ited to one side
Conclusion
The “key” for the right appro ach is to exclude the infec-
tious form, osteomyelitis pubis, and tubercular osteo-
myelitis, and differe ntiate them by means of aspiration
and histological evaluation. Only then can a rational and
specific therapy be initiated. In our case, we had a high
index of clinical suspicion based on patient profile and
initial non response to conservative management. FNAC
was diagnostic of Tuberculosis and patient was started
on ATT for which he responded. Timely diagnosis and
intervention is thus a key to treatment and helped in
reducing the morbidity and deformities.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompany-
ing images. A copy of the writ ten consent is available
for review by the Editor-in-Chief of this journal.

Authors’ contributions
KB and SP reviewed the literature and wrote the paper. VK and AKM
maintained all the records of the patient and followed him. All the authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 23 June 2010 Accepted: 27 August 2010
Published: 27 August 2010
References
1. Rodriguez C, Miguel A, Lima H, Heinrichs K: Osteitis pubis syndrome in the
professional soccer athlete: a case report. Journal of Athletic Training 2001,
36:437-40.
2. Ross JJ, Hu LT: Septic arthritis of the pubic symphysis: review of 100
cases. Medicine (Baltimore) 2003, 82:340-5.
3. Nicholson OR: Tuberculosis of the pubis; report of eleven cases. J Bone
Joint Surg Br 1958, 40(1):6-15.
4. Fares G, Pagani A: [Tubercular osteitis of the pubis] [Article in Italian].
Minerva Ortop 1966, 17(8):459-69.
5. Dybowski WR, Makuchowa K: [Tuberculosis of the pubic symphysis]
[Article in Polish]. Chir Narzadow Ruchu Ortop Pol 1974, 39(5):633-9.
6. Ker NB: Tuberculosis of the pubic symphysis. J R Soc Med 1986,
79(7):429-30.
7. Rozadilla A, Nolla JM, Rodriguez J, Del Blanco J, Roig Escofet D:
Tuberculosis of the pubis symphysis. J Rheumatol 1991, 18(8):1271-2.
8. Manzaneque L, Marin I, García-Bragado F, Beiztegui A, Dastis C, Sánchez-
Matas P: Osteoarticular tuberculosis of the symphysis pubis presenting
as a hypogastric cystic mass in a woman with primary Sjögren’s
syndrome. Br J Rheumatol 1992, 31(7):495-6.
9. Tsay MH, Chen MC, Jaung GY, Pang KK, Chen BF: Atypical skeletal
tuberculosis mimicking tumor metastases: report of a case. J Formos Med

Assoc 1995, 94(7):428-31.
10. Benbouazza K, Allali F, Bezza A, et al: [Pubic tuberculous osteo-arthritis.
Apropos of 2 cases][Article in French]. Rev Chir Orthop Reparatrice Appar
Mot 1997, 83(7):670-2.
11. Balsarkar DJ, Joshi MA: Tuberculosis of pubic symphysis presenting with
hypogastric mass. J Postgrad Med 2001, 47(1):54.
12. Bayrakci K, Daglar B, Tasbas BA, Agar M, Gunel U: Tuberculosis
osteomyelitis of symphysis pubis. Orthopedics 2006, 29(10):948-50.
13. Pauli S, Willemsen P, Declerck , Chappel R, Vanderveken M: Osteomyelitis
pubis versus osteitis pubis: a case presentation and review of the
literature. Br J Sports Med 2002, 36:71-3.
14. Knoeller SM, Markus Uhl, Georg Werner Herget: Osteitis or osteomyelitis of
the pubis ? A diagnostic and therapeutic challenge: report of 9 cases
and review of the literature. Acta Orthop Belg
2006, 72(5):541-48.
15. Burke G, Joe C, Levine M, Sabio H: Tc-99 m bone scan in unilateral osteitis
pubis. Clin Nucl Med 1994, 19(6):535.
doi:10.1186/1749-799X-5-63
Cite this article as: Bali et al .: Tuberculosis of symphysis pubis in a 17
year old male: a rare case presentation and review of literature. Journal
of Orthopaedic Surgery and Research 2010 5:63.
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